Medical Resources

Below are some medical resources to help you better understand the procedures we provide. If you have any questions, please consult your physician or contact us.

General Information

Procedures

Digestive System

The esophagus, stomach, and large and small intestines, aided by the liver, gallbladder and pancreas, convert the nutritive components of food into energy and break down the non-nutritive components into waste to be excreted.

Endoscopy refers to the use of an instrument called an endoscope - a thin, flexible tube with a tiny video camera and light on the end. The high quality picture from the endoscope is shown on a TV monitor; the resulting image gives your physician a clear, detailed view of your digestive tract. The endoscope is used by a highly trained medical specialist, a gastroenterologist, to diagnose and treat various problems of the GI tract.

Colon Cancer

Colon Cancer

Colorectal cancer is the second leading cause of death from cancer in the United States.

In recent years (1995-1999), the number of people diagnosed with colorectal cancer has stayed about the same, but the number of people who die from colorectal cancer has decreased. Colorectal cancer is found more often in men than in women.

Studies show that screening for colorectal cancer decreases the number of deaths from this disease.

Age and health history can affect the risk of developing colon cancer.

Anything that increases a person's chance of getting a disease is called a risk factor. Risk factors for colorectal cancer include the following:

Being older than 50 years of age.

Having a personal history of any of the following:

Colorectal cancer or adenomas.

Cancer of the ovary, endometrium, or breast.

Ulcerative colitis or Crohns Disease

Having a parent, brother, sister, or child with colorectal cancer or adenomas.

Kegel Exercises

Kegel exercises

It may take diligence to identify your pelvic floor muscles and learn how to contract and relax them. Here are some pointers:

Find the right muscles

To make sure you know how to contract your pelvic floor muscles, try to stop the flow of urine while you're going to the bathroom. If you succeed, you've got the basic move. Or try another technique: Insert a finger inside your vagina and try to squeeze the surrounding muscles. You should be able to feel your vagina tighten and your pelvic floor move upward. Then relax your muscles and feel your pelvic floor move down to the starting position. As your muscles become stronger -- and you become more experienced with the exercises -- this movement will be more pronounced.

A cautionary note: Don't make a habit of starting and stopping your urine stream. Doing Kegel exercises with a full bladder or while emptying your bladder can actually weaken the muscles. It can also lead to incomplete emptying of the bladder, which increases your risk of a urinary tract infection.

If you're having trouble finding the right muscles, don't be embarrassed to ask your doctor for help. He or she can provide important feedback so that you learn to isolate and exercise the correct muscles.

Perfect your technique

Once you've identified your pelvic floor muscles, empty your bladder and get into a sitting or standing position. Then firmly tense your pelvic floor muscles. Try it at frequent intervals for five seconds at a time, four or five times in a row. Work up to keeping the muscles contracted for 10 seconds at a time, relaxing for 10 seconds between contractions.

Be careful not to flex the muscles in your abdomen, thighs or buttocks. To get the maximum benefit, focus on tightening only your pelvic floor muscles. Also, try not to hold your breath. Just relax, breathe freely and focus on tightening the muscles around your vagina and rectum.

Repeat three times a day

Perform a set of 10 Kegel exercises at least three times a day. The exercises will get easier the more often you do them. You might make a practice of fitting in a set every time you do a routine task, such as checking e-mail or commuting to work.

You can also vary your technique. Try doing sets of mini-Kegels. Count quickly to 10 or 20, contracting and relaxing your pelvic floor muscles each time you say a number. Or slow it down, gradually contracting and releasing your pelvic floor muscles one time. As you contract, visualize an elevator traveling up four floors. At each floor, contract your muscles a little more until you reach maximum contraction at the fourth floor. Hold the contraction and then slowly release the tension as you visualize the elevator traveling back down. Repeat 10 times.

Some doctors recommend exercising the pelvic floor muscles with weighted vaginal cones about the size of tampons. By contracting your pelvic floor muscles, you hold the weight in place in your vagina. Start with a light weight and gradually work up to a heavier one.

Biofeedback may help

If you have trouble doing Kegel exercises, biofeedback training may help. In a biofeedback session a nurse, therapist or technician will either insert a monitoring probe into your vagina or place adhesive electrodes on the skin outside your vagina or rectal area. When you contract your pelvic floor muscles, you'll see a measurement on a monitor that lets you know whether you've successfully contracted the right muscles. You'll also be able to see how long you hold the contraction.

Another technique uses electrical stimulation to help you feel the muscles contract. The procedure is painless, although you'll experience a buzzing feeling as a small electrical current is applied to your pelvic floor muscles, making them contract. Once you feel this sensation a few times, you'll probably be able to duplicate the exercise on your own. Because simpler methods work for most women, this technique is rarely used.

When to expect results

If you do your Kegel exercises faithfully, you can expect to see some results, such as less frequent urine leakage, within about eight to 12 weeks. Your improvement may be dramatic -- or, at the very least, you may keep your problems from worsening. As with other forms of physical activity you need to make Kegel exercises a lifelong practice to get lifelong benefits.

Colonoscopy

What is the colon?

The colon, or large bowel, is the last portion of your digestive tract, or gastrointestinal tract. The colon is a hollow tube that starts at the end of the small intestine and ends at the rectum and anus. The colon is about 5 feet long, and its main function is to store unabsorbed food waste and absorb water and other body fluids before the waste is eliminated as stool.

What is a colonoscopy?

A colonoscopy (koh-luh-NAH-skuh-pee) allows a doctor to look inside the entire large intestine. The procedure enables the physician to see things such as inflamed tissue, abnormal growths, and ulcers. It is most often used to look for early signs of cancer in the colon and rectum. It is also used to look for causes of unexplained changes in bowel habits and to evaluate symptoms like abdominal pain, rectal bleeding, and weight loss.

PreparationYou will be given instructions in advance that will explain what you need to do to prepare for your colonoscopy. Your colon must be completely empty for the colonoscopy to be thorough and safe. To prepare for the procedure you will have to follow a liquid diet for 1 to 3 days beforehand. The liquid diet should be clear and not contain food colorings, and may include:

fat-free bouillon or broth

strained fruit juice

water

plain coffee

plain tea

diet soda

gelatin

Thorough cleansing of the bowel is necessary before a colonoscopy. You will likely be asked to take a laxative the night before the procedure. In some cases, you may be asked to give yourself an enema. An enema is performed by inserting a bottle with water and sometimes a mild soap in your anus to clean out the bowels. Be sure to inform your doctor of any medical conditions you have or medications you take on a regular basis such as:

aspirin

arthritis medications

blood thinners

diabetic medication

vitamins that contain iron

The medical staff will also want to know if you have heart disease, lung disease, or any medical condition that may need special attention. You must also arrange for someone to take you home afterward, because you will not be allowed to drive after being sedated.

We will also provide you with a prescription for a bowel preparation formula and instructions for use. The most common formulae we use are Moviprep, Suprep, Golytely, Prepopik and Osmoprep.

Procedure

For the colonoscopy, you will lie on your left side on the examining table. You will be given pain medication and a moderate sedative to keep you comfortable and help you relax during the exam. The doctor and a nurse will monitor your vital signs, look for any signs of discomfort, and make adjustments as needed.

The doctor will then insert a long, flexible, lighted tube into your rectum and slowly guide it into your colon. The tube is called a colonoscope (koh-LON-oh-skope). The scope transmits an image of the inside of the colon onto a video screen so the doctor can carefully examine the lining of the colon. The scope bends so the doctor can move it around the curves of your colon.

You may be asked to change positions at times so the doctor can more easily move the scope to better see the different parts of your colon. The scope blows air into your colon and inflates it, which helps give the doctor a better view. Most patients do not remember the procedure afterwards.

The doctor can remove most abnormal growths in your colon, like a polyp, which is a growth in the lining of the bowel. Polyps are removed using tiny tools passed through the scope. Most polyps are not cancerous, but they could turn into cancer. Just looking at a polyp is not enough to tell if it is cancerous. The polyps are sent to a pathology lab for testing. By identifying and removing polyps, a colonoscopy likely prevents most cancers from forming.

The doctor can also remove tissue samples to test in the lab for diseases of the colon (biopsy). In addition, if any bleeding occurs in the colon, the doctor can pass a laser, heater probe, electrical probe, or special medicines through the scope to stop the bleeding. The tissue removal and treatments to stop bleeding usually do not cause pain. In many cases, a colonoscopy allows for accurate diagnosis and treatment of colon abnormalities without the need for a major operation.

During the procedure you may feel mild cramping. You can reduce the cramping by taking several slow, deep breaths. When the doctor has finished, the colonoscope is slowly withdrawn while the lining of your bowel is carefully examined. Bleeding and puncture of the colon are possible but uncommon complications of a colonoscopy.

A colonoscopy usually takes 30 to 60 minutes. The sedative and pain medicine should keep you from feeling much discomfort during the exam. You may feel some cramping or the sensation of having gas after the procedure is completed, but it usually stops within an hour. You will need to remain at the colonoscopy facility for 1 to 2 hours so the sedative can wear off.

Rarely, some people experience severe abdominal pain, fever, bloody bowel movements, dizziness, or weakness afterward. If you have any of these side effects, contact your physician immediately. Read your discharge instructions carefully. Medications such as blood-thinners may need to be stopped for a short time after having your colonoscopy, especially if a biopsy was performed or polyps were removed. Full recovery by the next day is normal and expected and you may return to your regular activities.

Upper Endoscopy

Upper endoscopy enables us to look inside the esophagus, stomach, and duodenum (first part of the small intestine). The procedure might be used to discover the reason for swallowing difficulties, nausea, vomiting, reflux, bleeding, indigestion, abdominal pain, or chest pain. Upper endoscopy is also called EGD, which stands for esophagogastroduodenoscopy (eh-SAH-fuh-goh-GAS-troh-doo-AH-duh-NAH-skuh-pee).

For the procedure you will swallow a thin, flexible, lighted tube called an endoscope (EN-doh-skope). Right before the procedure we will spray your throat with a numbing agent that may help prevent gagging. You may also receive pain medicine and a sedative to help you relax during the exam. The endoscope transmits an image of the inside of the esophagus, stomach, and duodenum, so we can carefully examine the lining of these organs. The scope also blows air into the stomach; this expands the folds of tissue and makes it easier for us to examine the stomach.

We can see abnormalities, like inflammation or bleeding, through the endoscope that don't show up well on x rays. We can also insert instruments into the scope to treat bleeding abnormalities or remove samples of tissue (biopsy) for further tests.

Possible complications of upper endoscopy include bleeding and puncture of the stomach lining. However, such complications are rare. Most people will probably have nothing more than a mild sore throat after the procedure.

The procedure takes 20 to 30 minutes. Because you will be sedated, you will need to rest at the endoscopy facility for 1 to 2 hours until the medication wears off.

Preparation

Your stomach and duodenum must be empty for the procedure to be thorough and safe, so you will not be able to eat or drink anything for at least 6 hours beforehand. Also, you must arrange for someone to take you home -- you will not be allowed to drive because of the sedatives.

Flexible Sigmoidoscopy

Flexible sigmoidoscopy (SIG-moy-DAH-skuh-pee) enables us to look at the inside of the large intestine from the rectum through the last part of the colon, called the sigmoid or descending colon. Physicians may use the procedure to find the cause of diarrhea, abdominal pain, or constipation. We also use it to look for early signs of cancer in the descending colon and rectum. With flexible sigmoidoscopy, the physician can see bleeding, inflammation, abnormal growths, and ulcers in the descending colon and rectum. Flexible sigmoidoscopy is not sufficient to detect polyps or cancer in the ascending or transverse colon (two-thirds of the colon).

For the procedure, you will lie on your left side on the examining table. Your physician will insert a short, flexible, lighted tube into your rectum and slowly guide it into your colon. The tube is called a sigmoidoscope (sig-MOY-duh-skope). The scope transmits an image of the inside of the rectum and colon, so the physician can carefully examine the lining of these organs. The scope also blows air into these organs, which inflates them and helps the physician to better see.

If anything unusual is in your rectum or colon, like a polyp or inflamed tissue, your physician can remove a piece of it using instruments inserted into the scope. The physician will send that piece of tissue (biopsy) to the lab for testing.

Bleeding and puncture of the colon are possible complications of sigmoidoscopy. However, such complications are uncommon.

Flexible sigmoidoscopy takes 10 to 20 minutes. During the procedure, you might feel pressure and slight cramping in your lower abdomen. You will feel better afterward when the air leaves your colon.

Preparation

The colon and rectum must be completely empty for flexible sigmoidoscopy to be thorough and safe, so the physician will probably tell you to drink only clear liquids for 12 to 24 hours beforehand. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea, or diet soda. The night before or right before the procedure, you may also be given an enema, which is a liquid solution that washes out the intestines.

ERCP

Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (en-doh-SKAH-pik REH-troh-grayd koh-LAN-jee-oh-PANG-kree-uh-TAH-gruh-fee) (ERCP) enables us to diagnose problems in the liver, gallbladder, bile ducts, and pancreas. The liver is a large organ that, among other things, makes a liquid called bile that helps with digestion. The gallbladder is a small, pear-shaped organ that stores bile until it is needed for digestion. The bile ducts are tubes that carry bile from the liver to the gallbladder and small intestine. These ducts are sometimes called the biliary tree. The pancreas is a large gland that produces chemicals that help with digestion and hormones such as insulin. ERCP is used primarily to diagnose and treat conditions of the bile ducts, including gallstones, inflammatory strictures (scars), leaks (from trauma and surgery), and cancer. ERCP combines the use of x rays and an endoscope, which is a long, flexible, lighted tube. Through the endoscope, we can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x rays. For the procedure, you will lie on your left side on an examining table in an x-ray room. You will be given medication to help numb the back of your throat and a sedative to help you relax during the exam. You will swallow the endoscope, and your physician will then guide the scope through your esophagus, stomach, and duodenum until it reaches the spot where the ducts of the biliary tree and pancreas open into the duodenum. At this time, you will be turned to lie flat on your stomach, and the physician will pass a small plastic tube through the scope. Through the tube, your physician will inject a dye into the ducts to make them show up clearly on x rays. X rays are taken as soon as the dye is injected. If the exam shows a gallstone or narrowing of the ducts, your physician can insert instruments into the scope to remove or relieve the obstruction. Also, tissue samples (biopsy) can be taken for further testing. Possible complications of ERCP include pancreatitis (inflammation of the pancreas), infection, bleeding, and perforation of the duodenum. Except for pancreatitis, such problems are uncommon. You may have tenderness or a lump where the sedative was injected, but that should go away in a few days. ERCP takes 30 minutes to 2 hours. You may have some discomfort when the physician blows air into the duodenum and injects the dye into the ducts. However, the pain medicine and sedative should keep you from feeling too much discomfort. After the procedure, you will need to stay at the hospital for 1 to 2 hours until the sedative wears off. The physician will make sure you do not have signs of complications before you leave. If any kind of treatment is done during ERCP, such as removing a gallstone, you may need to stay in the hospital overnight.

Preparation

Your stomach and duodenum must be empty for the procedure to be accurate and safe. You will not be able to eat or drink anything after midnight the night before the procedure, or for 6 to 8 hours beforehand, depending on the time of your procedure. Also, your physician will need to know whether you have any allergies, especially to iodine, which is in the dye. You must also arrange for someone to take you home -- you will not be allowed to drive because of the sedatives. Your physician may give you other special instructions.

Endoscopic Ultrasonography

The combination of the ultrasound probe and an endoscope has led to the development of EUS scopes, or echoendoscopes. These instruments allow examination of both the lining of the digestive tract with the endoscope and the wall of the tract and its surrounding structures such as the liver, pancreas, bile ducts, and lymph nodes. Many other structures can also be seen. Because of these unique capabilities, EUS can sometimes detect abnormalities or obtain information other imaging tests cannot. EUS procedures can be done via the mouth (Upper EUS) or via the rectum (Rectal or Lower EUS).

It is also possible to study the flow of blood in vessels through a process known as Doppler ultrasound or pass a small needle down the endoscope and direct it, under ultrasonic guidance, into structures within or adjacent to the digestive tract, such as lymph nodes or suspicious masses. In this way, tissue can be aspirated for analysis by a pathologist. This technique is known as fine needle aspiration (FNA).

Indications

EUS procedures can provide a variety of information. They are primarily used to detect suspected cancers or to evaluate how far a previously diagnosed cancer has spread in order to determine the appropriate therapy, which is called staging. EUS is used to stage cancers of the esophagus, stomach, pancreas, and rectum. Spread to adjacent lymph nodes and blood vessels can be determined by the imagining fine-needle aspiration capabilities of EUS.

EUS is also useful in identifying the nature of "lumps" and "bumps" seen on a previous endoscopic exam. These bumps may represent an adjacent structure compressing the GI tract or represent a mass or fluid collection within the wall of the digestive tract. EUS can help differentiate between these possibilities.

EUS also plays a role in evaluating disorders of the pancreas and bile ducts (the tubes that drain bile from your liver and gall bladder). Visualization of the bile ducts is easily accomplished, and the pancreas can be evaluated for the presence of masses, cysts, or changes that suggest chronic inflammation. Other uses of EUS include evaluating patients with fecal incontinence or stage lung cancers and searching for clots in the vessels of the abdomen using Doppler ultrasound.

PreparationBring any x-rays or other relevant tests you have undergone with you. When you arrive at the endoscopy unit, be sure to give your doctor a complete list of all the medicines you are taking and any allergies you have to drugs or other substances. You should specifically mention to your medical team if you are taking any aspirin-containing products, arthritis medicines such as ibuprofen, anticoagulants (blood thinners), or diabetic medications, or you have heart, lung, or other medical conditions that may need special attention before, during, or after your procedure.

You will be given instructions in advance that will outline what you should and should not do in preparation for your procedure. Be sure to read and follow these instructions carefully.

One very important aspect of your preparation is not eating or drinking within six hours of the procedure. Food in the stomach will block the view through the endoscope.

At the Endoscopy Suite

Upon arriving, you will change into a hospital gown and remove any glasses, contacts and dentures you may have. An intravenous needle (IV) will be placed (typically in your arm) into which your sedative medications will be injected when the procedure begins. A detailed medical history will be obtained by the medical staff and you'll be asked to sign a form that verifies your consent to proceed with the test and your understanding of what is involved.

After signing the consent form, you will be taken to the specially equipped procedure room and connected to monitors that will measure your heart rate, your blood pressure, and the oxygenation levels of your blood throughout the procedure. You will be asked to turn onto your left side, and a plastic guard will placed into your mouth to protect your teeth if you are having an Upper EUS. The sedation will then be administered through your IV. Complete anesthesia is rarely necessary. The medications are used to provide relief from discomfort as well as to cause "amnesia", which usually results in your not remembering much, if anything, about the test. At this point, the procedure will begin.

Procedure

During the procedure, we will do everything to help you be as comfortable as possible. Your blood pressure, your pulse, and the oxygen level in your blood will be carefully monitored. As the echoendoscope is slowly and carefully inserted, air will be introduced through it to help your doctor to see better. Typically, an EUS procedure lasts between 30 and 90 minutes. Depending on the abnormalities seen, your doctor may choose to collect some tissue samples during the procedure. This can be done with biopsy forceps or via a fine needle aspiration (FNA) procedure. If a fluid collection is seen, it can be suctioned through the scope and sent for analysis. Occasionally, if there is a large cyst in the pancreas that needs drainage, your doctor may place a stent through the stomach or small bowel into the pancreatic cyst.

For patients with pancreatic cancer or severe pain, medications can be injected into the nerves responsible for transmitting this pain. This serves to lessen the pain in these patients for a period of up to several months and is called a celiac-plexus blockade. Based on current evidence, it appears to work better for patients with pancreatic cancer than it does for patients with chronic pancreatitis.

Possible Complications

EUS has been shown to be a safe procedure, similar to other types of endoscopy. The risks are similar to regular endoscopy, except when fine needle aspiration is performed.

First, there is a small risk of having a reaction to the sedative medications or antibiotics that may be given prior to your procedure. This usually results in nausea or a skin rash and usually goes away quickly. Medications to reverse the effects of the sedatives are available, if necessary.

The major risks are perforation (a puncture of the intestinal wall), which could require surgical repair, and bleeding, which could require transfusion. Again, these complications are unlikely. They typically occur from passing the scope through a large tumor or "stretching" or dilating a tumor before or during the EUS procedure.

The risks associated with FNA include bleeding, pancreatitis (rarely, and only if the pancreas undergoes FNA), or infection. In patients undergoing a rectal FNA or an FNA of any cystic lesion, intraprocedural antibiotics are given and followed up with a 5-day course of oral antibiotics after the procedure.

After the Procedure

You will be cared for in a recovery area until most of the effects of the medication have worn off. Typically, this takes 1-2 hours, which is longer than for standard endoscopy. You will likely have to go home with someone else after the procedure. We will give you a prescription for a 5-day course of oral antibiotics if an FNA of a cyst or rectal lesion was performed. You will also be given guidelines for resuming your normal activity before leaving the endoscopy unit.

We will give you a phone number to call, should you experience severe abdominal pain, difficulty swallowing, fever, vomiting up blood, bloody bowel movements, or extreme dizziness/weakness. It is important to contact your physician if you experience any of these effects.

Liver Biopsy

In a liver biopsy (BYE-op-see), the physician examines a small piece of tissue from your liver for signs of damage or disease. A special needle is used to remove the tissue from the liver. The physician decides to do a liver biopsy after tests suggest that the liver does not work properly. For example, a blood test might show that your blood contains higher than normal levels of liver enzymes or too much iron or copper. A CT scan or ultrasound could suggest that the liver is swollen. Looking at liver tissue itself is the best way to determine whether the liver is healthy or what is causing it to be damaged.

Preparation

Before scheduling your biopsy, we will take blood samples to make sure your blood clots properly. Be sure to mention any medications you take, especially those that affect blood clotting, like blood thinners. One week before the procedure, you will have to stop taking aspirin, ibuprofen, and anticoagulants.

You must not eat or drink anything for 8 hours before the biopsy, and you should plan to arrive at the hospital about an hour before the scheduled time of the procedure. Your physician will tell you whether to take your regular medications during the fasting period.

Procedure

Liver biopsy is considered minor surgery, so it is done at the hospital. For the biopsy, you will lie on a hospital bed on your right lateral back with your right hand above your head. The physician may use an ultrasound image of the liver to help guide the needle to a specific spot. After marking the outline of your liver and injecting a local anesthetic to numb the area, your physician will make a small incision in your right side near your rib cage, then insert the biopsy needle and retrieve a sample of liver tissue.

The physician will ask you to hold your breath for 5 to 6 seconds while he or she puts the needle in your liver. You will need to hold your breath very still so that your physician does not nick the lung or gallbladder, which are close to the liver. You may feel pressure and a dull pain. The entire procedure takes about 20 minutes.

Two other methods of liver biopsy are also available. Transvenous biopsy involves inserting a tube called a catheter into a vein in the neck and guiding it to the liver. The physician puts a biopsy needle into the catheter and then into the liver. Physicians use this procedure when patients have blood-clotting problems or fluid in the abdomen. For a laparoscopic biopsy, the physician inserts a special tube called a laparoscope through an incision in the abdomen. The laparoscope sends images of the liver to a monitor. The physician watches the monitor and uses instruments in the laparoscope to remove tissue samples from one or more parts of the liver. Physicians use this type of biopsy when we need tissue samples from specific parts of the liver.

Recovery

After the biopsy, your physician will put a bandage over the incision and have you lie on your right side, pressed against a towel, for 2 hours. The nurse will monitor your vital signs and level of pain. After that time, you need remain in bed (except to use the bathroom) for additional 2 hours in the recovery room, where your vital signs and level of pain will be closely monitored.

You will need to arrange for someone to take you home from the hospital since you will not be allowed to drive after having the sedative. You must go directly home and remain resting (except to use the bathroom, eat, or bathe) for the next 12 hours, depending on your physician's instructions. Also, avoid exertion for the next week so that the incision and liver can heal. You can expect a little soreness at the incision site and possibly some pain in your right shoulder. This pain is caused by irritation of the diaphragm muscle (the pain usually radiates to the shoulder) and should disappear within a few hours or days. Your physician may recommend that you take Tylenol for pain, but you must not take aspirin or ibuprofen for the first week after surgery. These medicines decrease blood clotting, which is crucial for healing.

Like any surgery, liver biopsy does have some risks, such as puncture of the lung or gallbladder, infection, bleeding, and pain, but these complications are rare.

Esophageal Manometry

The esophagus is the tube that carries food and liquid from the throat to the stomach. Although it seems like a simple organ, the esophagus is not a rigid tube. The wall of the esophagus a muscle that rhythmically contracts whenever a person swallows. This contraction occurs as a sweeping wave (peristalsis) carrying food down the esophagus. It literally strips the food or liquid from the throat to the stomach. Another important part of the esophagus is the lower valve muscle (lower esophageal sphincter, or LES). This is a specialized muscle that remains closed most of the time, only opening when swallowed food or liquid is moved down the esophagus or when a person belches or vomits. This muscle protects the lower esophagus from caustic stomach acid and bile. These substances, of course, cause the discomfort of heartburn and in time can lead to damage and scarring in the esophagus. At times, everyone has heartburn, especially after a large or fatty meal. Manometry is the recording of muscle pressures within an organ; esophageal manometry measures the pressure within the esophagus. It can evaluate the action of the stripping muscle waves in the main portion of the esophagus as well as the muscle valve at the end of it. The equipment for manometry consists of thin tubing with openings at various locations. When this tube is positioned in the esophagus, these openings sense the pressure in various parts of the esophagus. As the esophagus squeezes on the tube, these pressures are transmitted to a computer analyzer that records the pressures on moving graph paper, much like an electrocardiogram. The physician can evaluate these wave patterns to determine if they are normal or abnormal.

IndicationsThere are a number of symptoms that originate in the esophagus. These include difficulty swallowing food or liquid, heartburn, and chest pain. Additionally, an x-ray (barium swallow or upper GI series) or endoscopy may show abnormalities that need further study by manometry. The exam is often done before and after medical or surgical treatment of the esophagus. Esophageal manometry is very effective in evaluating the contraction function of the esophagus in many situations. After the exam, the physician has clear documentation of the muscle function of the esophagus. With this information, a specific treatment program can be outlined, or reassurance can be provided if the exam is normal.

Preparation

The patient should take no food or liquid for about eight hours before the exam. The physician will usually (although not always) want to study the esophagus in its natural state. The following drugs may affect the contractile pattern of the esophagus. They usually need to be discontinued at least 48 hours beforehand. Check with your physician about all your medications.

Caffeine/coffee

Reglan (generic: metoclopramide)

Urecholine (generic: bethanechol)

Erythromycin (antibiotic - many brand names)

Nitroglycerin (Isordil, Nitro-Bid, others)

Calcium channel blockers (Procardia, Adalat, Calan, cardizem, others)

Betablockers (Inderal, Corgard, others)

Donnatol

Librax

Levsin

Tagamet (generic: cimetidine)

Zantac (generic: ranitidine)

Pepcid (generic: famotidine)

Axid (generic: nizatidine)

Prilosec (generic: omeprazole)

Prevacid (generic: lansoprazole)

Procedure

The procedure takes about one hour from start to finish. While you are seated in a chair or lying on your side, thin soft tubing is gently passed through the nose, or occasionally the mouth. Upon swallowing, the tip of the tube enters the esophagus and the technician then quickly passes it down to the desired level. There is usually some slight gagging at this point, but it is easily controlled by following instructions. During the exam, the technician usually asks the patient to swallow saliva (called a dry swallow) or water (called a wet swallow). Pressure recordings are made and the tubing is withdrawn. Patients can usually resume regular activity, eating, and medicines immediately after the exam.

24 Hour Esophageal pH Study

A 24 hour esophageal pH study is used to measure the number of reflux episodes a patient has in one day. The study also measures the amount of time (in minutes) that stomach acid is present in the patient's esophagus. The 24 hour test allows for evaluation of the patient's symptoms with activity, at home or work, and especially during sleep.

The information obtained from this study will show if acid reflux is the cause of non-cardiac chest pain, hoarseness, coughing, halitosis, or asthma. This study can show how much reflux a patient is having when endoscopy findings are normal. This information will assist your physician in planning treatment for your particular health problem. Your appointment will last about one hour; this includes out-patient admission, instruction and placement of the pH catheter.

Your procedure will take place in an examination room. Usually, no sedation is given. A nurse will spray your throat with a topical anesthetic and use an anesthetic lubricant on the small, flexible pH tube. The tube is 1/8 inch in diameter, about a third the size of a pencil. This tube is gently placed in one nostril and guided into your esophagus. The end of the tube is positioned 2 inches above the diaphragm, where acid sensing occurs. You will be lying on an examination table during the placement. You do not have to remove your clothing, and you may have a companion with you during examination.

After the pH catheter is placed, the catheter is secured with small pieces of silk tape to the end of your nose and the side of your face. The catheter is attached to a "Walkman" type recorder that is worn on a belt, which is provided. You will not be able to bathe or shower with this catheter in place. Some patients find this catheter does not interfere with their normal activities; others find it to be annoying and would appreciate having someone to drive them home. It may make your eyes water, your nose run, and your throat sore. You will have to return to DCCVA 24 hours later for removal of the catheter. This second visit will take about 5 minutes.

Upper GI Series

The upper gastrointestinal (GI) series uses x rays to diagnose problems in the esophagus, stomach, and duodenum (first part of the small intestine). It may also be used to examine the small intestine. The upper GI series can show a blockage, abnormal growth, ulcer, or problem with the way an organ is working.

During the procedure, you will drink barium, a thick, white, milkshake-like liquid. Barium coats the inside lining of the esophagus, stomach, and duodenum, and makes them show up more clearly on x rays. The radiologist can also see ulcers, scar tissue, abnormal growths, hernias, or areas where something is blocking the normal path of food through the digestive system. Using a machine called a fluoroscope, the radiologist is also able to watch your digestive system work as the barium moves through it. This part of the procedure shows any problems in how the digestive system functions, for example, whether the muscles that control swallowing are working properly. As the barium moves into the small intestine, the radiologist can take x rays of it as well.

An upper GI series takes 1 to 2 hours. X rays of the small intestine may take 3 to 5 hours. It is not uncomfortable, but the barium may cause constipation and white-colored stool for a few days after the procedure.

Preparation

Your stomach and small intestine must be empty for the procedure to be accurate, so the night before you will not be able to eat or drink anything after midnight.

Lower GI Series

A lower gastrointestinal (GI) series uses x rays to diagnose problems in the large intestine, which includes the colon and rectum. The lower GI series may show problems like abnormal growths, ulcers, polyps, diverticulitis, and colon cancer.

Before taking x rays of your colon and rectum, the radiologist will put a thick liquid called barium into your colon. This is why a lower GI series is sometimes called a barium enema. The barium coats the lining of the colon and rectum and makes these organs, and any signs of disease in them, show up more clearly on x rays. It also helps the radiologist see the size and shape of the colon and rectum.

You may be uncomfortable during the lower GI series. The barium will cause fullness and pressure in your abdomen and will make you feel the urge to have a bowel movement. However, that rarely happens because the tube used to inject the barium has a balloon on the end of it that prevents the liquid from coming back out.

You may be asked to change positions while x rays are taken. Different positions give different views of the colon. After the radiologist is finished taking x rays, you will be able to go to the bathroom. The radiologist may also take an x ray of the empty colon afterwards.

A lower GI series takes about 1 to 2 hours. The barium may cause constipation and make your stool turn gray or white for a few days after the procedure.

Preparation

Your colon must be empty for the procedure to be accurate. To prepare for the procedure you will have to restrict your diet for a few days beforehand. For example, you might be able to drink only liquids and eat only sugar-free, nondairy foods for 2 days before the procedure, drink only clear liquids the day before, and consume nothing after midnight the night before. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea, or diet soda. To make sure your colon is empty, you will be given a laxative or an enema before the procedure.

Colon Cancer Screening

The following recommendations are for persons who have never had a colorectal cancer or pre-cancerous polyps (adenomatous type polyps). These are derived from the American College of Gastroenterology. You may visit the ACG website at acg.gi.org for more information.

Persons at Average Risk

Average risk persons are defined as age 50, a normal physical exam, absence of symptoms, absence of family history of colorectal cancer or colorectal polyps, and no evidence of microscopic blood within the stool (fecal occult blood test cards) on 3 sequential tests.

Recommendation: Colonoscopy every 10 years starting at age 50.Alternative Strategy: Annual fecal occult blood tests (3) plus sigmoidoscopy every 5 yr.NB: If annual fecal occult blood test cards are positive for blood, a colonoscopy should be performed regardless of the number of cards that are positive.

Moderately Increased Risk

Moderately increased risk persons are defined as those persons with one first-degree relative (mother, father, or sibling) with colorectal cancer diagnosed at age 60 or older.

High-risk persons are defined as those persons with two or more first-degree relatives (mother, father or sibling) with colorectal cancer diagnosed at age less than 60.

Recommendation: Colonoscopy starting at age 40 or 10 years less than the youngest affected relative whichever is earlier.Colonoscopy should be repeated every 3 to 5 years.Alternative Strategy: No alternative screening modalities are considered adequate.

Infrared Coagulation

Infrared Coagulation (IRC) is the most widely used office treatment for hemorrhoids and is preferred over other methods because it is fast, well-tolerated by patients, and virtually problem-free. A small probe contacts the area above the hemorrhoid, exposing the tissue to a burst of infrared light for about one second. This coagulates the veins above the hemorrhoid, causing it to shrink and recede. The patient may feel a sensation of heat very briefly, but it is generally not painful. Therefore, anesthetics are usually not required.

There are generally no side effects. Most patients return to a normal lifestyle the same day. There may be slight spot bleeding a few days later. Heavy straining or lifting should be avoided and aspirin should not be taken for a few days.

Many patients have more than one hemorrhoid. Therefore, most physicians recommend two or three visits at two-week intervals, treating a different portion of the hemorrhoid tissue each visit.

Hemorrhoids treated with IRC generally do not recur. A sensible diet moderate exercise and proper bowel habits will help.